Gardens of North Olmsted

In the surveyor’s words

From the most serious findings on record at Gardens of North Olmsted, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 13, 2026

  Based on observation, medical record review, resident interview, staff interview, law enforcement interview, sexual assault nurse examiner (SANE) interview, certified nurse practitioner (CNP) interview, therapeutic provider interview, review of witness statements, review of a local police department report, review of hospital and emergency department (ED) records, review of a self-reported incident (SRI), review of an electronic mail (email) correspondence document, and review of a facility policy, the facility failed to protect Resident #1's right to be free from sexual abuse by Resident #76. […]

• No harm, potential for more than minimal, widespreadF725May 18, 2026

  Based on observation, resident and staff interviews, and review of daily staff schedules, staff time punch detail, daily posted nurse staffing, the Facility Assessment (FA), and the Payroll Based Journal (PBJ) report, the facility failed to have sufficient staffing. This affected one resident (Resident #10) reviewed for incontinence care, five residents (Residents #2, #29, #52, #67 and #78) who voiced staffing concerns, and had the potential to affect all 78 residents residing in the facility. Findings include:1. Review of the PBJ report for the third quarter of 2025 revealed the facility had a one-star staffing rating and was identified with low weekend staffing.2. Review of the FA, not dated, revealed the following:The average daily census was 73. […]

• No harm, potential for more than minimal, widespreadF727May 18, 2026

  Based on review of staff schedules, staff time punch detail and interview, the facility failed to ensure the Director of Nursing (DON) worked full-time as the DON and did not work as a staff nurse when the census was over 60. This had the potential to affect all 78 residents residing in the facility.Findings include:Review of staff schedules and time punch detail for DON revealed she worked as a staff nurse on 04/08/26 from 9:11 A.M. to 7:00 P.M.; 04/11/26 from 7:08 A.M. to 7:24 P.M.; 04/20/26 from 08:41 A.M. to 7:38 P.M., 04/21/26 from 8:48 A.M. to 8:35 P.M., 04/22/26 from 8:00 A.M. to 6:37 P.M., 04/25/26 from 3:44 P.M. to 6:00 P.M., 04/27/26 from 8:36 P.M. to 11:30 P.M., 04/29/26 from 7:44 A.M. to 11:31 P.M, and 05/01/26 from 10:14 A.M. to 11:12 P.M. Interview on 05/11/26 at 4:30 P.M. […]

• No harm, potential for more than minimal, widespreadF804May 18, 2026

  Based on observation, interview, and review of facility dietary menus, the facility failed to ensure meals were served at a palatable temperature. This affected three residents (Residents #11, #29 and #67) and had the potential to affect all other residents who received meals from the kitchen. The facility indicated one resident (Resident #2) who received nothing by mouth. The facility census was 78.Findings include:Interview on 05/12/26 at 9:52 A.M. with Resident #67, who was noted to receive a mechanical soft diet, stated the food was not good and the portions were not always big enough.Interview on 05/11/26 at 11:18 A.M. with Resident #29, who was noted to receive a regular no added salt diet, stated the meals were frequently cold.Interview on 05/11/26 at 12:46 P.M. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2026

  Based on observation, interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen and failed to ensure resident room refrigerators were monitored and maintained as required. This had the potential to affect all residents receiving meals from the kitchen, and affected three residents (Residents #18, #29 and #35) of three residents reviewed for room refrigerators. The facility indicated one resident (Resident #2) who received nothing by mouth. The facility census was 78.Findings include:1. Observation on 05/11/26 at 8:31 A.M. with Dietary Manager (DM) #550 during the initial kitchen tour revealed the outside of the convection ovens had multiple dried stains and the handles were sticky. […]